Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> } ENVIRONMENTAL HEALTH PERMIT r <br /> LIQUID WASTE <br /> Application " ereby made carry n busin ss in he jyrisdi 'onal area of the Sa+;l Joa uin Local Health District <br /> Com+ Address °` -7,/- <br />' rBusiness Name ( BA) I y <br /> r Owner Address <br /> 4 <br /> J Firm Partners, Addresses a d Telephone Numbers <br /> aBusiness Telephone No.. � G Emergency Telephone No. <br /> Contractor Licence No. �� —�� <br /> Title Date <br /> LApplicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information i <br /> i 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites \ <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal,,Weights &Measures No. <br /> ti Equipment Parking Address <br /> fPUMPER � <br /> 2. ❑ YARD <br /> For July 1, June 30, 19 <br /> r <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test tion Test Date/Time <br /> 4. It SANITATION PERMIT <br /> Job Addres /Location Z_ntlo 10-1 <br /> Owne Address <br /> ❑ SEPTIC TANK ❑ CE POOL �1 ❑ LEACHING FIELDEPAGE PIT ❑ PACKAGE PLANT T� <br /> ❑ PERMANENT ❑ TEMPORARY LJ ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,i iii-June 30, 19 <br /> Type Construction �1 Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT tFor July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> ( Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> { I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County S <br /> ordinances, state laws, and r %d regulations of San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X � <br /> FOR DEPARTMENT USE ONLY <br /> i. Fee Is Due: ❑ ANNUALLY [jPER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &R ei ed <br /> REMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT UE CHECKED - <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS t <br /> ' PRORATION , <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER G <br /> –. -- p ' 14 <br /> R <br /> Date Rece;pS No- a Permit No. Issuance ate ,Mailed D ivered <br /> eceived by <br /> _ <br /> 1641 E.HAZELTON AVE.,P.O.Box 2009 � STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO:; ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />